Violence and Residual Associations Among Native Americans Living on Tribal Lands

Adam Hardy, Kathleen Brown-Rice


The article reviews the empirical literature regarding exposure to violence among Native Americans living on tribal lands. The prevalence of various types of violence experienced by this population is identified. Predictive characteristics correlated with higher rates of violence among Native Americans living in tribal communities have been reported by researchers to include socioeconomic status, unemployment, gender, cultural affiliation, substance abuse, relationship status, history of violence exposure, and adverse childhood experiences. Residual associations include PTSD, anxiety, depression, chronic pain, substance abuse, promiscuity, suicidal ideation, communal deterioration, and cardiovascular disease. Barriers for addressing mental health needs in this population, implications for mental health counselors and directions for research are provided.


Keywords: Native Americans, tribal lands, violence, predictive characteristics, residual associations


The treatment of Native American populations has not been a traditional area of focus among mental health researchers (Matamonasa-Bennett, 2013). However, a push for increased knowledge in the effective treatment of this population has led to an influx of empirical attention in the past few decades. The National Congress of American Indians declared violence against Native Americans, particularly those living on tribal lands, as the most critical issue faced by Native Americans (Matamonasa-Bennett, 2013). Complicating the interpretations of the subsequent studies, Evans-Campbell (2008) concluded significant differences between Native Americans living on tribal lands and Native Americans living in urban areas. It is critical that counselors be cognizant of such within- group differences (Brown-Rice, 2013). Research efforts related to Native American populations living in tribal communities have predominately focused on exposure to violence. In order to bridge the gap in understanding how violence impacts Native Americans, the current review addresses the prevalence, predictive characteristics and residual associations related to violence among Native American men and women living on tribal lands. Moreover, the barriers to addressing mental health treatment among this population are discussed. Implications for counselors and directions for research are provided.


Violence and Mental Health Issues for Native Americans


Violence can consist of physical, sexual and emotional assault (Watts & Zimmerman 2002). Many acts of violence can be characterized as a combination of these categories, such as a sexual assault that also produces physical harm to the survivor. Physical violence can include assault, neglect of basic needs (which is most common among children), exploitation of labor and false imprisonment. Sexual violence includes rape, fondling, genital mutilation and sex trafficking (Watts & Zimmerman, 2002). Emotional violence includes isolation, verbal abuse, economic abuse, coercion, threats and intimidation (Pence & Paymar, 1993). Because violence is often conceptualized as a means to gaining or maintaining power and control over others, a survivor of violence is often victimized by those closest to him or her, such as a family member or friend (Watts & Zimmerman, 2002).


     Post-traumatic stress disorder (PTSD) has been associated with exposure to physically, sexually and emotionally violent experiences (Ford, Grasso, Elhai, & Courtois, 2015). Traumatic stress symptoms are often more complicated to treat in circumstances when an individual has been exposed to prolonged or repeated violence. Furthermore, these symptoms are more likely to develop when survivors of violence feel a sense of betrayal from the perpetrator, which is often reported by those who experience sexual assault and domestic abuse (Ford et al., 2015). Researchers have concluded that these issues are more prevalent among Native Americans living on tribal lands (Malcoe, Duran, & Montgomery, 2004; Yuan, Koss, Polacca, & Goldman, 2006), which may suggest a higher likelihood for the development of PTSD when compared to other populations.


Although PTSD is the mental health disorder most often associated with individuals who experience violence, depression (Cascardi, O’Leary, & Schlee, 1999) and anxiety (Pico-Alfonso et al., 2006) symptoms have been highly correlated to violence exposure. Clearly, those who survive violence are at high risk of developing mental health symptoms and can benefit from professional intervention. However, the experiences of Native Americans related to violence are not likely to be completely congruent to other populations (Sue & Sue, 2012). For this reason, it is crucial for counselors to gain increased competency in the unique factors impacting the Native American community in order to provide effective care.


Violence Against Native American Women


United States legislators acknowledged in the 2005 Violence Against Women Act (VAWA) that Native American women living on tribal lands were a particularly marginalized population (Crossland, Palmer, & Brooks, 2013). VAWA mandated that several governmental organizations begin a series of research efforts in order to better understand the prevalence and residual consequences experienced by this population when violence was present (Crossland et al., 2013). Bryant-Davis, Heewoon, and Tillman (2009) concluded that the studies succeeding VAWA indicated that violence against women had significantly decreased in the 10 years preceding the studies for every population except Native American women. These researchers also concluded that Native American women living on tribal lands account for the highest rates of exposure to violence compared to any other population. Despite these conclusions, Matamonasa-Bennett (2013) reported that Native American women continue to be underrepresented in research regarding violence against women.


Prevalence of Violence Against Native American Women

Determining the precise prevalence of violence among Native American women living on tribal lands is a complicated endeavor. There can be substantial differences between communities, leading to frequent misinterpretation in the results of research (Yuan et al., 2006). It is common that researchers report the prevalence of violence among Native Americans, even though the results of their studies accounted for the prevalence among a specific tribe. For this reason, it is important not to make generalizations regarding reports that do not expand to various regions by examining the methodological decisions of the researchers in order to better interpret the results (Gone, 2010). In response to the need for clarity on the prevalence of violence in tribal communities, Oetzel and Duran (2004) concluded that many researchers asked vague questions and excluded common types of physical violence, prompting them to investigate exposure to violence among Native American women by asking a wider range of specified questions. They determined that women in tribal communities reported the prevalence of violence exposure at rates ranging from 46–91%. They compared these results to non-Native populations, which had previously reported prevalence rates ranging from 7–51%. Similarly, Wahab and Olson (2004) examined the prevalence of physical violence among Native American women living on tribal lands while accounting for vast differences between tribes. These researchers concluded that this population experienced higher rates of physical violence than women of any other ethnicity.


While researching violence among Native American women, many researchers have focused on domestic violence. In a study spanning 12 distinct tribal communities, researchers reported that 58.7% of Native American women had been victims of domestic violence, resulting in severe physical trauma in 39.1% of these women (Malcoe et al., 2004). Hart and Lowther (2008) reported domestic violence incidents had increased each of the past 10 years prior to their study, indicating that this issue is escalating in tribal communities. Moreover, Native American women have reported higher levels of re-victimization than other female populations (Urquiza & Goodlin-Jones, 1994). L. Jones (2008) concluded that Native American women living on tribal lands found it difficult to leave violent relationships due to communal feedback which encourages victims to protect their abusers. Because Native American women are more likely than other women to be recurrently assaulted, there may be implications for the development of complex traumatic stress symptoms (Ford et al., 2015).


Sexual assault also appears to be a common form of violence experienced by Native American women. Prevalence rates of rape among this population have been reported as high as 34.1%, which is nearly twice the rates among other women in the United States (Tjaden & Thoennes, 2000). Behaviors of perpetrators of sexual assault on tribal lands also have been studied among researchers. When surveyed about sexual assault history, Native American women living in tribal communities have reported male relatives as the most often cited perpetrator of sexual assault, accounting for 55% of the incidents (Yuan et al., 2006). Significant percentages of perpetration of sexual assault also have been attributed to romantic partners (46%), acquaintances (29%) and strangers (28%). The likelihood of developing complicated traumatic stress symptoms may be increased due to the high frequency of sexual assault of Native American women by individuals who are familiar to them (Ford et al., 2015). Moreover, it appears that once a Native American woman living on tribal land is exposed to sexual violence, the likelihood of subsequent exposure is high. The recurrence of sexual assault among this population has been reported to be as high as 79% (Roodman & Clum, 2001).


Predictive Associations of Violence Against Native American Women

Malcoe, Duran, and Ficek (2002) concluded that socioeconomic status is a significant predictor of exposure to violence among Native American women living on tribal land. Specifically, women who have reported low socioeconomic characteristics are two and half times more likely to be exposed to physical violence (Malcoe et al., 2002; Oetzel & Duran, 2004). Specifically, it was reported that Native American women living on tribal lands who were receiving governmental financial assistance were nearly two and a half times more likely to report exposure to physical violence. According to the United States Census Bureau (2014), less than half of the residents of the Pine Ridge reservation in South Dakota were employed between 2010 and 2014. As a result, 52.2% of those living in this area were below poverty standards, which is well above the national average of 14.8%.


     Native American women living on tribal lands with substance abuse issues are at a higher risk for exposure to both physical and sexual violence (Yuan et al., 2006). Substance abuse issues among individuals close to Native American women have been reported to predict exposure to violence. Native American women with alcohol abuse issues, for example, reported significant levels of exposure to domestic violence (Yuan et al., 2006). Furthermore, Native American women have reported heavy alcohol use by 62% of their perpetrators, compared to 42% from women of other ethnic backgrounds (Ferraro, 2008). There is evidence to suggest that Native American women living on tribal land who identify with traditional Native American culture are less likely to be associated with substance abuse and related physical violence (Whitbeck, Adams, Hoyt, & Chen, 2004). Conversely, Native American women living on tribal land who report higher associations with traditional Native American culture have reported increased frequency of exposure to sexual violence (Yuan et al., 2006). However, increased focus on traditional Native American culture could be a coping mechanism used by women following victimization, potentially making cultural affiliation a residual effect of violence.


When considering sexual violence, the factor most predictive of exposure in Native American populations has been concluded to be gender (Yuan et al., 2006). Both Native American men and women are sexually assaulted, but Native American women report sexual assault at rates 14 times higher than males (Yuan et al., 2006). The relationship status of women living on tribal lands also has been correlated to exposure to sexual violence. Women engaged in cohabitating relationships and women separated and divorced were concluded by researchers to be at a higher risk for sexual violence (Bryant-Davis et al., 2009). Moreover, Bryant-Davis and Ocampo (2006) postulated that Native American women are sexually assaulted at higher rates than women of other ethnicities due to systematic eroticization, devaluation and objectification by American culture.


     Yuan et al. (2006) reported that Native American women living on or near tribal lands who experience emotional abuse as children report significantly higher rates of sexual violence exposure as adults. Similarly, women in this population who have survived sexual and physical abuse before the age of 18 are more likely to be raped in adulthood. Because a history of emotional, sexual or physical abuse appears to significantly contribute to the predictability of future exposure to violent traumatic stressors, increased attention on providing interventions to young Native American populations may prove beneficial for prevention efforts (Yuan et al., 2006).


Residual Associations of Violence Against Native American Women

Arbuckle et al. (1996) concluded that Native American women are three times more likely to be murdered than Latino and White women. Hence, death is a relatively common residual association to violence among this population. Witnessing homicide also can be a form of exposure to violence. When homicide occurs, there are often secondary victims seeking mental health services. Family and friends of a victim of homicide within the Native American population often report cognitive patterns of self-blame, which exacerbates mental health symptoms (Weinberg, 1994).


Native American women exposed to physical violence have reported high levels of traumatic stress symptoms (B. Duran et al., 2009). In a study that surveyed 3,084 Native Americans living on tribal lands across the United States, women reported PTSD symptoms with a frequency twice the rate of men (Buchwald, Goldberg, Noonan, Beals, & Manson, 2005). It was concluded that 16% of women living on tribal lands met the criteria for PTSD, which is 6% higher than the national average for women (Ford et al., 2015). Exposure to violence on tribal lands also has been associated with increased likelihood to develop mood disorders, anxiety disorders (B. Duran et al., 2009) and chronic pain (Buchwald et al., 2005).


The relationship between exposure to violence in tribal communities by Native American women and mental health disorders was examined by Oetzel and Duran (2004). These researchers concluded that physical injuries and medical assistance on tribal lands were highly correlated with symptoms of depression and that increased exposure to violence appeared to lead to negative sociological effects such as unemployment. Oetzel and Duran theorized that exposure to physical violence on tribal lands could be directly linked to chronic pain and psychological symptoms which limit the capacity for Native American women to change their environment when desired.


It is common that persons exposed to violence display high-risk behaviors, including substance abuse and sexual promiscuity (Hobfoll et al., 2002). It is believed that these behaviors can be conceptualized as a means of coping with traumatic stressors (Ford et al., 2015). Substance abuse, which has been identified as a predictive factor to physical violence exposure, also appears to be a residual association. Saylors and Daliparthy (2005) concluded that Native American women often use alcohol and illicit drugs in order to numb cognitive and emotional reactions to physical and sexual violence. Furthermore, among Native American women living in tribal communities, those with a history of exposure to violence are five times more likely to contract sexually transmitted infections when compared to women with no history of exposure to violence (Hobfoll et al., 2002). As a result, this population is more likely to contract HIV than women in other communities. When the spread of sexually transmitted infections is intentional or the risks are disregarded by carriers, it can be conceptualized as sexual abuse, even when sex is consensual. When considering the spread of HIV, this act can be criminal (Hobfoll et al., 2002).


Despite the high rates of sexual assault victimization that have been reported by Native American women living on tribal lands, residual effects of exposure to sexual violence have not been a major focus by researchers (Bryant-Davis et al., 2009). However, there have been several associations that have been linked to rape. Similar to what researchers have concluded from studying the effects of exposure to physical violence, researchers have concluded that Native American women living on tribal lands who reported a history of sexual violence victimization display high frequencies of symptoms that meet the criteria for PTSD and other anxiety disorders (Bryant-Davis et al., 2009). Perhaps related to this phenomenon is the research indicating that this population has reported high levels of suicidal ideation and more frequent suicidal attempts than women in other communities following sexual violence exposure (Bohn, 2003). Among Native American women who attempted suicide in one tribal community, 87% reported exposure to some level of sexual violence and 59% reported exposure to rape (Bohn, 2003).



Violence Against Native American Men


     A review of the literature on violence experienced on tribal lands reveals that the majority of the focus has been on the prevalence, predictive factors and residual associations of exposure to violence among Native American women. Although men living in these areas have received less attention, it is important to be familiar with the available research related to the victimization of men. Gaining a broader understanding of how all individuals living on tribal lands experience violence will assist in the ability to be sensitive to issues faced by both men and women and aid counselors to choose culturally competent interventions.


Prevalence of Violence Against Native American Men

Robin, Chester, Rasmussen, Jaranson, and Goldman (1997) reported that among Native American men residing in Southwest tribal communities, 81% reported exposure to a violent act at some point in their lives. Among Native American men living on seven tribal communities in Montana, nearly one in ten reported exposure to physical violence in the year preceding the survey (Harwell, Moore, & Spence, 2003). This figure was nearly double the prevalence reported by women living in the same communities, although women reported higher frequencies of sexual violence and emotional abuse (Harwell et al., 2003). A study on the prevalence of aggravated assault among Native Americans living on tribal lands found that men were victims of severe physical violence at a rate of 36% since turning 18 years of age (Yuan et al., 2006). These reports suggested that although women may be exposed to various types of violence at higher rates in tribal communities, men may be subject to a higher likelihood of physical injury due to exposure to higher rates of physical violence.


Native American men are more likely than men of any other ethnicity to experience traumatic brain injury (TBI) as a result of violence (Nelson, Rhoades, Noonan, & Manson, 2007). Moreover, Native American men living in rural tribal communities are more likely to seek medical attention for a TBI than those living in urban areas (Nelson et al., 2007). Hence, a Native American man living on tribal lands appears to have a higher risk than any other population in the United States to experience severe enough violence to sustain an injury to the brain. The only comparable population was concluded to be African-American men living in urban inner-city communities (Nelson et al., 2007).


Although domestic violence is typically considered by many to be a women’s issue, Robin, Chester, and Rasmussen (1998) surveyed both men and women living on tribal lands about their lifetime and recent prevalence of intimate partner violence experiences. These researchers concluded that men reported rates of lifetime prevalence of domestic violence at 91%, with 31% reporting recent exposure to violence perpetrated by intimate partners. However, despite these high rates, men were concluded to be less likely to need medical assistance as a result of domestic violence when compared to the women in their tribal communities.


Predictive Associations of Violence Against Native American Men

     Homicide occurrence among Native American men living on tribal lands has been reported to be highly correlated to unemployment and impoverished standards of living (Lester, 1995). Criminal mentalities that often accompany a lack of occupational routine and structure may contribute to increases in the capacity to commit homicide (Lester, 1995). It is possible that factors that lead to unemployment, such as substance use, play a role in the propensity to experience or commit homicide in tribal communities (Koss et al., 2003).


Yuan et al. (2006) investigated the predictive characteristics of physical violence exposure among Native American men living in six distinct tribal communities, studying the effects of variations in demographics, alcohol dependence in adulthood, cultural variables, regional variables, and adverse childhood experiences on the prevalence for physical violence victimization. The researchers concluded that only adverse childhood experiences and alcohol dependence in adulthood mediated the likelihood of exposure to violence across similar communities.


Native American men under the age of 18 have been studied by researchers to determine predictive characteristics and protective factors related to the perpetration and exposure to physical violence. Pu et al. (2013) concluded that men under the age of 18 living on tribal lands have more desire to learn and practice traditional Native American culture than the women in their similar age ranges. The men who reported high levels of desire to practice their traditional culture also displayed higher levels of self-efficacy to avoid perpetration and victimization of physical violence. High levels of parental involvement were associated with lower levels of exposure to violence among this population.


Residual Associations for Violence Against Native American Men

     While the prevalence and predictive characteristics of exposure to violence among Native American men living on tribal lands have been understudied, there have been higher rates of contributions from empirical literature regarding the residual associations related to victimization. When surveyed using qualitative methods, Native American men reported that one substantial observed consequence of violence on tribal lands is the expanding discrepancies between traditional Native American values and behaviors witnessed in tribal communities (Matamonasa-Bennett, 2013). These men reported beliefs that Native American men did not frequently commit violence against Native American men or women until the introduction of colonization and alcohol. These men feared that continued trends in violence would serve to further the gap between the values held by traditional Native American culture and the values of those living on tribal lands.


Beals et al. (2013) studied PTSD among 1,446 Native Americans living in southwest tribal communities and 1,638 Native Americans living in Northern Plains tribal communities. Rates of traumatic stress symptomology that suggested PTSD were reported to vary between 5.9% and 28.3% for Native American men. On average, men reported rates of PTSD at 14.8%, which is approximately triple the national average for men (Ford et al., 2015). Therefore, although Native American women living on tribal lands have reported higher rates of PTSD than men, the discrepancy between the rates on tribal lands and the national average is far more pronounced for Native American men than it is for women. Beals et al. also concluded that Native American men were just as likely to develop traumatic stress symptoms (15.9%) as men in other populations following exposure to traumatic stressors. This indicates that the increased frequency of PTSD among Native American men living on tribal lands is a function of increased exposure to traumatic experiences. There also may be certain types of violence that lead to increased likelihood for the development of PTSD. Researchers have reported that sexual violence exposure has been associated with increased anxiety symptoms among Native American men (Gnanadesikan, Novins, & Beals, 2005). Furthermore, Native American men who have experienced six or more incidents of violence are significantly more likely to develop traumatic stress symptoms. Indeed, PTSD is a prevalent and serious residual effect of exposure to violence in tribal communities.


Cardiovascular disease (CVD) has been concluded to be higher among Native American men living on tribal lands when compared to men in other populations (Sawchuk et al., 2005). When researchers have examined factors that correlate to CVD, only exposure to violent traumatic stressors and subsequent traumatic stress symptoms have been significantly correlated to increased likelihood for CVD. General stress and the presence of depression do not account for the same variance on CVD as traumatic stress (Sawchuk et al., 2005). It is possible that exposure to violence among Native American men can lead to decreased life expectancy due to serious heart conditions.


Similar to the reports of residual associations for Native American women who experience violence, Native American men living on tribal lands with a history of victimization report increased prevalence of high-risk behaviors, including substance abuse (M. C. Jones, Dauphinais, Sack, & Somervell, 1997). Because high-risk behaviors can be considered both predictive characteristics and residual effects of exposure to violence, these behaviors can seemingly serve to initiate and exacerbate violence. For example, if a Native American man abuses alcohol, effectively lowering inhibitions, he may find himself at increased risk to be subjected to a physical altercation. As a result, the man may turn to alcohol as a means to cope with reactions to the exposure to violence, creating a cycle of substance abuse that heightens the likelihood of future exposure to violence, culminating in the need for mental health care.


Barriers to Mental Health Care


Native American victims of violence are more likely than other populations to require medical care due to the severity of the sustained injuries (Bachman, Zaykowski, Lanier, Poteyeva, & Kallmyer, 2010). Because the development of PTSD is more frequent when physical trauma occurs as a result of violence (Ford et al. 2015), it is possible that Native Americans living on tribal lands are a population with an increased need for effective mental health interventions. The Indian Health Service (IHS) is the primary medical and mental health agency providing care to Native Americans on tribal lands (Katz, 2004). The IHS system has chronically reported issues with underfunding and understaffing due, in part, to legislative policies that do not allow for funds to be provided to IHS through the United States government. As a result, the care that individuals receive through the agency is often lacking in comparison to the standards of non-tribal health care agencies. Furthermore, these services are not guaranteed to those with Native American heritage, and nearly half of the low-income Native American individuals on tribal lands cannot afford health insurance (Katz, 2004). Effectively, this renders the population within tribal lands as having the highest risk for exposure to violence, yet with limited resources to treat the effects of violence.


The largest barrier to receiving mental health care in the wake of a sexual violence crisis for Native Americans living on tribal lands may be the lack of available services within a reasonable distance. Juraska, Wood, Giroux, and Wood (2014) examined 873 Sexual Assault Response Teams (SARTs) within a designated proximity to Native American lands. SARTs are teams that provide emergency mental health care and advocacy to survivors of sexual assault and are widely used in the United States on both tribal and non-tribal lands. They reported that only 30.7% of these lands fell within a 60-minute driving range from a SART or sexual assault examiner. These researchers also reported that more than two-thirds of the tribal lands in the continental United States would not be accessible to SARTs and 381 of the 605 tribal communities were left with no coverage. Considering the high level of sexual violence that has been reported on tribal lands, it appears that SARTs are not being deployed in the areas that may need mental health care and advocacy the most.


In the area of domestic violence, researchers have concluded that significant stigmas have led to underreporting of violence by women to IHS staff (Clark, 2001). Specifically, Native American women have shared with researchers that they refused to report incidents of domestic violence to IHS staff because of the manner in which the topic was addressed and fear regarding how the staff may react. Moreover, although screening for domestic violence has become commonplace among medical facilities in the United States, only 62% of the surveyed IHS facilities had protocols to screen for domestic violence (Clark, 2001). If survivors of violence do not feel safe reporting violence to their medical and mental health professionals, appropriate aid cannot be deployed to prevent the development (or exacerbation) of traumatic stress symptoms. Furthermore, it has been theorized that Native American men and women underreport violence to IHS staff because of altered perceptions as to what constitutes violence (Tehee & Esqueda, 2008). In particular, incidents that may be reported as abuse by other populations may not be severe enough to be considered reportable violence by Native American individuals living on tribal lands.


Furthermore, a general lack of multicultural competency displayed by counselors toward Native Americans appears to be a significant barrier for this population receiving adequate mental health care. Although there has been a push for increased multicultural competency in the field of counseling in the last decade (Toporek & Vaughn, 2010), educational institutions have not traditionally focused on providing counselors-in-training the capacities for effectively working with diverse cultures (Garrett & Herring, 2001; Ponterotto, Casas, Suzuki, & Alexander, 2009; Sue, Arredondo, & McDavis, 1992). Even the theories that have enjoyed the most empirical support, such as cognitive behavioral therapy, have been scrutinized for a general lack of applicability to diverse cultures (Graham, Sorenson, & Hayes-Skelton, 2013). In fact, many common therapeutic approaches may serve to further marginalize minority populations by expecting clients to conceptualize issues and develop problem-solving strategies from the dominant culture perspective (Sue & Sue, 2012).


     Even when research and educational entities commit to better competency in understanding and working with minority populations, the majority of the attention is allotted to Hispanic, Black, and Asian populations. It is theorized that these phenomena may contribute to low rates of mental health seeking behaviors and high rates of dropout from Native American clients (Garrett & Herring, 2001). Moreover, it has been theorized that counselors, due to multicultural competency deficiencies, may even reinforce continued physical and sexual violence in Native American populations by focusing only on a client’s behavioral flaws as a means of therapeutic intervention (E. Duran, Duran, Heart, & Horse-Davis, 1998). Clearly, increased efforts in training counselors to work with Native American clients are necessary to adequately provide mental health services to this high-need population.


Implications for Counselors


To summarize, Native Americans living on tribal lands are at a higher risk for exposure to violence than other populations (Wahab & Olson, 2004). Predictive characteristics associated with increased risk include low socioeconomic status (Malcoe et al., 2002), unemployment (Lester, 1995), gender (Oetzel & Duran, 2004), cultural affiliation (Yuan et al., 2006), substance abuse (Ferraro, 2008), relationship status (Roodman & Clum, 2001), history of previous exposure to violence (Bryant-Davis et al., 2009), and adverse childhood experiences (Yuan et al., 2006). Residual associations to experiencing violence on tribal lands include PTSD (Beals et al., 2013; B. Duran et al., 2009), symptoms of anxiety and depression (Bryant-Davis et al., 2009), chronic pain (Buchwald et al., 2005), substance abuse (Yuan et al., 2006), increased high-risk behaviors such as promiscuity (Hobfoll et al., 2002), suicidal ideation (Bohn, 2003), decreased communal cohesion (Matamonasa-Bennett, 2013), and cardiovascular disease (Sawchuk et al., 2005).


Barriers experienced by Native Americans living on tribal lands for obtaining mental health services have been identified as poor standards in IHS agencies (Katz, 2004), inability to access mental health crisis SARTs (Juraska et al., 2014), underreporting of violence by Native American clients (Clark, 2001), and a lack of multicultural competency displayed by counselors (Garrett & Herring, 2001). In understanding barriers faced by Native Americans living on tribal lands, counselors can make informed decisions about intervention strategies that best aid clients in overcoming these barriers. This may mean altering therapeutic intervention approaches, increasing focus on establishing positive working alliances with clients through increased cultural competency, meeting with clients in their local communities, and advocating for systemic change in governmental and mental health agencies. Working to help eliminate the barriers to obtaining mental health services among Native Americans living on tribal lands may be the difference between those who fall into the cycle of re-victimization and those who break this cycle through collaborative efforts with the counselor.


Despite the disheartening research revealing the prevalence of violence among Native Americans living on tribal lands, this phenomenon does not appear to be common knowledge or an area of passion among some mental health counselors. Without a shift in the ways counselors view and treat violence within this population, oppression which lends to violence exposure and consequent mental health issues is not likely to subside as a result of mental health intervention. In particular, mental health counselors must commit to gaining increased competency in working with Native Americans and advocate for effective and ethical therapeutic strategies.


Counseling Practice Implications

Although many clinical approaches have been reported to exhibit limited effectiveness when working with Native American populations, some researchers have attempted to expand on empirically validated approaches in order to increase the likelihood of effectiveness with this population. Bigfoot and Schmidt (2010) adapted cognitive behavioral therapy (CBT) approaches to incorporate teachings from the traditional Native American Medicine Wheel. These researchers concluded that their method of therapy was particularly beneficial for Native American children with traumatic stress symptoms. When working with Native American survivors of trauma, counselors can expand this model by incorporating the Native American Medicine Wheel throughout the cognitive restructuring process.


The Native American Medicine Wheel is comprised of four sections with various concepts dedicated to each section. The wheel symbolizes how various elements in one’s life are separate, yet interconnected. When utilizing the wheel as an intervention tool, counselors can focus on the sections dedicated to thoughts, emotions, behavior and spirituality. CBT aims to help clients identify, challenge and change dysfunctional thought patterns in order to alter emotions and behaviors. Therefore, the counselor can use the Native American Medicine Wheel as a guide to help the client conceptualize how change is created. It may be beneficial to begin by focusing on the section dedicated to spirituality in order to gain insight into the spiritual beliefs and values held by the client. The knowledge gained in this process will help the counselor to understand what spiritual practices may be incorporated into sessions. The counselor can proceed by focusing on the sections dedicated to cognition, emotion and behavior. The suggested goals for counseling sessions are provided in Figure 1.

















Figure 1. Incorporating the Native American Medicine Wheel into CBT.



As the counselor and client move through these sections, the counselor also can incorporate the other elements within each section. For example, while processing the section dedicated to emotion, the counselor can incorporate visual imagery of summer and water while practicing relaxation techniques. The counselor and client can process how the role of the teacher applies to training oneself to cope with environmental triggers. It is further suggested that the counselor find opportunities to use traditional Native American healing methods during counseling sessions such as (a) smudging, (b) using Native American symbols to represent new topics, (c) incorporating Native American languages, (d) creating visual representations using Native American art forms, (e) forming talking circles, and (f) consulting with elders in the tribal communities (Bucharski, Reutter, & Ogilvie, 2006). Counselors also should be educated on the theory of historical trauma to assist clients in understanding how the traumas of the past impact the Native American community today. Native American clients should be educated regarding how previous traumas can impact current behavior across generations (Brown-Rice, 2013).


Although several researchers have called for increased focus on spiritual exercises while working with Native American clients (Bucharski et al., 2006; Matheson, 1996), counselors must be cautious when implementing these interventions. Matheson (1996) urged non-Native American counselors to consider the difference between cultural competencies and understanding. He reported that non-Native counselors often attempt to implement a Native American spiritual exercise as the counselor understands it, which can prove to be misguided, counterproductive and offensive. Instead, it is best to collaborate with Native American clients about how an activity should be executed and seek permission to engage in the exercise with the client. This will help to account for any violations of sacred practices and saturate the power between the counselor and client. Matheson theorized that Native Americans are often turned away from counseling due to perceived power differential and lack of interdependence between the counselor and client.


There also may be environmental changes that can be incorporated into counseling that help facilitate spiritual expression when working with Native American clients. For example, counselors may decide to hold counseling sessions outside of an office setting. A counselor may take the client to a garden or observe nature while conducting counseling sessions. Moreover, a counselor may use pet therapy techniques to help Native American clients feel a connection to nature. This technique also may help clients to express empathy (Hunter & Sawyer, 2006). Again, it is best if the counselor collaborates with the client to ensure that the setting changes are congruent with the personal beliefs and values of the client.


When a high level of exposure to traumatic stressors is present, as it often is with Native American populations, a client is likely to have biological and environmental needs that supersede mental health counseling. Targeting these needs early in the counseling relationship is likely to increase the ability of the client to meet counseling objectives. B. Jones, Tilden, and Gaines-Stoner (2008) suggested a multi-modal approach to working with Native Americans living on tribal lands due to the nature of complex trauma. First, Jones suggested that counselors build the therapeutic alliance with Native American clients by demonstrating a high level of value for sharing, autonomy and informal interpersonal interaction. Second, Jones suggested that counselors be active in consulting with agencies to provide aid with substance abuse services, housing, legal assistance, transportation, childcare and job development.


Of course, a multi-modal approach would be particularly difficult to implement for Native Americans who present with substantial barriers to mental health care. Although it is crucial that the counseling field advocate for bureaucratic changes, creating a trusting and therapeutic rapport with Native American clients is the barrier that counselors must address immediately. Native Americans living on tribal lands prefer counselors who are sensitive to Native American values and use a non-directive theoretical approach to counseling (Bichsel & Mallinckrodt, 2001). This suggests that counselors who employ more directive approaches, such as the cognitive behavioral techniques previously described, may incorporate increased person-centered approaches while building the initial working alliance with Native American clients. Native Americans have reported a preference for frequent use of collaboration (Scholl, 2006) and little use of concrete advice-giving in counseling (Garrett, 2003).


Counselors can give special considerations to Native American clients when they have been exposed to sexual violence. In particular, counselors can aid these individuals in the process of identifying and challenging self-blame and shame; survivors of sexual assault report feelings of shame and self-blame at a rate of 75% (Vidal & Petrak, 2007). Perspectives of survivors have been linked to negative self-concept (Miller, Handley, Markman, & Miller, 2010) and PTSD (Ullman, Townsend, Filipas, & Starzynski, 2007). It is important to note that the relationship between self-blame and PTSD has been theorized to be mediated by negative social reactions (Ullman et al., 2007). This suggests that processing blame and taking a position of unconditional positive regard toward the client can function to decrease PTSD symptoms.


High levels of self-blame among survivors of physical and sexual violence can serve as a predictor for re-victimization. Miller, Markman, and Handley (2007) reported increased re-victimization rates among survivors of sexual assault who reported elevated levels of self-blame. These conclusions were echoed by Edwards, Kearns, Gidycz, and Calhoun (2012), who determined that women who reported high levels of self-blame were more likely to remain in an intimate relationship with perpetrators of domestic abuse. Although there is no research available regarding the role self-blame plays among Native Americans living on tribal lands, it is clear that counselors must assess for self-blame when working with this population. In order to accomplish this task, and to collect needed research data, counselors can administer the Sexual Assault Symptom Scale (SASS), which includes subscales for self-blame, disclosure shame, safety fears and depression (Ruch, Gartrell, Amedeo, & Coyne, 1991).


Directions for Future Research


In order to increase the effectiveness of counseling interventions with Native American clients, there are several areas that warrant investigation. First, researchers should gain a better understanding of the differences between Native American tribes. The rate of violence exposure between tribes varies greatly (Oetzel & Duran, 2004), with some tribal communities being less impacted. Thus, researchers should conduct a more thorough examination of the prevalence, predictive characteristics and residual associations related to exposure to violence in tribal communities to determine the practices of those with lower levels of violence. In better understanding these factors, researchers can focus their attention on specified preventative approaches utilized by these communities and guide future counseling practices.


Furthermore, researchers should devote increased efforts to collecting data on male Native American survivors of violence. Certainly, researchers have investigated assault and homicide among this population, but prevalence and residual factors related to domestic and sexual violence is lacking in the literature. Many male survivors of physical and sexual assault are hesitant to report their experiences due to social factors including (a) fear of judgment by peers, (b) fear they will not be believed, (c) fear of being labeled homosexual, and (d) concerns about counselors maintaining confidentiality (Sable, Danis, Mauzy, & Gallagher, 2006). However, it is not known what additional factors may contribute to the hesitation of Native American men to report violence. Increased knowledge in this area could have significant implications for the prevention of violence on tribal lands among men, as well as positively impact the counseling process.


The negative impact that self-blame has on survivors of trauma has been well established (Miller et al., 2010; Ullman et al., 2007). However, the impact of self-blame in the Native American community, the population most affected by exposure to violence, has not been researched. It is important for counselors to know whether the existing research on self-blame is applicable to the Native American community in order to understand whether techniques must be altered. If self-blame was determined to be more or less prevalent among this population, researchers can help instruct counselors how to alter interventions to better account for cultural factors.


Researchers should aim to better understand the barriers to Native Americans living on tribal lands in obtaining mental health services. Specifically, the interpersonal factors in seeking services, the capacity of individuals to find services, and the role of bureaucracy in limiting resources should be further investigated. Gaining a greater understanding of efficient methods of deploying mental health services to Native American populations is only beneficial if administering services is a realistic possibility. Given that Native American people have a history of being diminished and marginalized in the interest of research (Walters & Simoni, 2009), research efforts need to be conducted in a culturally appropriate and ethical manner (Brown-Rice, 2013). If the mental health community were to commit to these research endeavors, it would provide a sufficient foundation for creating changes in the effectiveness of the treatment of this highly victimized population.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.






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Adam Hardy, NCC, is a Counselor at Glory House in Sioux Falls, SD. Kathleen Brown-Rice, NCC, is an Assistant Professor at the University of South Dakota. Correspondence can be addressed to Adam Hardy, 3005 West Courtyard Lane, Sioux Falls, SD 57108,